HomeMy WebLinkAboutCLE201500168 Application 2015-08-17ov :uau,
Application for Zonin Clearance::_
CLE #
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS Check# 16VD Date:
Receipt # i W l L*'Lcl Staff: ,iii-.
PARCEL INFORMAT�Q��, -1 _
Tax, Map and Parcel: ``�� Existing Zoning
Parcel Owner: 7uv rrC/
ac j J/ A /1171 � I d'D Cit 0 P /Mate �—:!A" zip;aq�
Parcel Address: S•P.
(include suite or floor)
PRIMARY CONTACT Rt ``,�1 l � E awn
Who should we call/write concerning this project.
Address : 1 i)1`� �� City U) State Zip
Office Phone: l✓ 't-1'—Rell # Fax # E-mail
APPLICANT INFORMATION
Check any that apply: Change of owners
'Business Name/Type:
Previous Business on this
Describe the proposed business including use, number of empl
v hicles, and any additional information hat you can provide:
*This Clearance will only be valid on the parcel for which
Clearance will be required.
!hange of use Change of name New business
iyee num er of shifts, availably parking spaces, number o
If you change, intensify or move the use to a new location, a new Zoning
I hereby certify that I own or have the owner's permission to use the space indicated on this application. I also certify that the information provided
is true and accurate to the best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature
Printed
APPROVAL INFORMATION Denied
',Approved as proposed [ ] Approved with conditions ]
[ ] Backflow prevention device acid/or current test data needed for this site. Contact ACSA, 977-4511, x117.
[ ] No physical site inspection has been done for this clearance. Therefore, it is not a determination of compliance with the existing
site plan.
[ ] This site complies with the site plan as of this date.
Notes:
Building Official
Zoning Official
Other Official
Date
Date
Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 rax: (434) 972-4126
Revised 7/1/2011 Page 2 of 3
Intake to complete the following:
Is use LI, 1-11 or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Will )ue be food preparation?
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies -
Is parcel on private well or )lie w, er?
If private well, provide Heal artment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applie
Is parcel on septic or p is rc sewer
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
CYC/ N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit 4 2-,)1Y— U NC
Reviewer to complete the following:
Square footage of Use: �}
N
Permitted as: r4-
Under Section: I -2--)
Supplementary regulations section:
Parking formula �` vLuVoa�'� /��¢� -LJ9✓� 6IiA5
Required spaces:
Y/
Items to be verified in the field;
Inspector:
Notes:
Date:
zoning to complete the following:
Viola�t�e s:
Y//N�
If so°°°°,----IrrIst:
Y/ Prof s:
If so, ist;
S' ariance:
/ N
If so, List:. --7 _5L/
4 !
/ N
If so, List:
_�
S
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3'
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